Provider Demographics
NPI:1851672281
Name:BLACK, ANGELA MARGARET (LMT)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARGARET
Last Name:BLACK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 26TH ST W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-2496
Mailing Address - Country:US
Mailing Address - Phone:850-819-9769
Mailing Address - Fax:
Practice Address - Street 1:2120 26TH ST W STE 101
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-2495
Practice Address - Country:US
Practice Address - Phone:850-819-9769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA48397225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist